Barbara Singer and Michael Pistiner
Managing anaphylaxis in school is a big job! School nurses are critical partners in the front line of managing anaphylaxis and have crucial roles in policy creation, implementation, and education. School nurses are relied upon to identify and assess students who are experiencing anaphylaxis, and they must have the skills to act swiftly and appropriately when an allergic reaction occurs. In addition, school nurses play an equally important role in training others and working with our nurse and physician colleagues to manage life threatening allergies in the school setting.
This is easier said than done.
In this blog, we will address the commonly asked question: What is the correct dose of epinephrine that should be prescribed to a student who is experiencing anaphylaxis?
Students who have a known potentially life threatening allergy should have an Anaphylaxis Emergency Care Plan (ECP) at school. The ECP should clearly state epinephrine as the drug of choice to treat anaphylaxis as delays in treatment can increase the risk of death.
In addition to treating students who have known life threatening allergies, school nurses also encounter students who experience anaphylaxis in school who have no previously known allergies. Each state has laws and policies regarding protocols that address anaphylaxis and epinephrine administration in these individuals.
However, questions remain as to how much epinephrine is enough?
Auto-injector (EpiPen, Auvi-Q (recently recalled), Adrenaclick, and generic epinephrine) package inserts all list epinephrine dosing to be 0.15mg for persons 33-66 pounds and 0.3mg for persons equal to or greater than 66 pounds. However, recommendations from the National Institute of Allergy and Infectious Diseases (NIAID), The American Academy of Pediatrics (AAP), and the National Association of School Nurses (NASN) are to upsize from the 0.15mg dose to the 0.3mg dose for persons who weigh equal to or greater than 55 pounds. A NASN/NASSNC/AAP workgroup created a sample protocol for treatment of anaphylaxis that clearly provides appropriate dosing guidelines [NOTE: Since this article was published, the sample protocol has been retired.]. More evidence to support epinephrine dosing parameters can be found in an AAP article.
It is up to each school nurse to be familiar with his/her individual state laws regarding epinephrine and, nurses can and should have a voice in the development of policies and protocols surrounding this issue. School nurses are instrumental in educating our school communities, having a collaborative relationship with area physicians, and communicating with providers regarding the need for standing orders for stock epinephrine and appropriate epinephrine dosing. School nurses who work with physicians, parents, staff, and students provide optimal care and save lives!
Additional Resources: Archived NASN Webinar (Recorded 10/22/2014): “Food Allergy and Anaphylaxis Myths: Don’t Let These Get in the Way of Effective School Management.”
References
National Association of School Nurses. (2014). Sample protocol for treatment of symptoms of anaphylaxis-Epinephrine auto-injector administration by school health professional and trained personnel for school age children-Kindergarten-grade 12. National Association of School Nurses Online. Retrieved from Resources/Food Allergy and Anaphylaxis.
Schoessler, Sally & Pistiner, Michael. (2014). Food allergy and anaphylaxis myths: Don’t let these get in the way of effective school management. Archived NASN Webinar. Food Allergy & Anaphylaxis Myths.
Schoessler, Sally, & White, Martha. (2013). Recognition and treatment of anaphylaxis in the school setting: The essential role of the school nurse. The Journal of School Nursing, 29(6), 407-415. doi: 10.1177/1059840513506014
Sicherer, Scott H. and Simons, Estelle R. (2007). Self-injectable epinephrine for first-aid management of anaphylaxis. Pediatrics, 119(3), 638-646. doi: 10.1542/peds.2006-3689
Barbara Singer, MSN, RN, NCSN, is a school nurse at Natick High School in MA, and is an Epinephrine Resource School Nurse for Massachusetts. She previously worked at the elementary level and in critical care.
Michael Pistiner MD, MMSc is a Boston based pediatric allergist who is heavily involved in food allergy and anaphylaxis management and education in the school setting, passionate about fostering collaborations between school nurses and health care providers, and co-founder of AllergyHome.org, a free web based resource for food allergy and anaphylaxis management. Go to the site for many school resources.